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CLINICAL RESEARCH AND METHODS Qualitative Research: Stigma Associated with Psychiatric Diseases Manal Koura Latifa Al-Sowielem Badria al-Dabal Raja’a A. Shaheed Afaf Al-Halal Najwa Al-Mahfoodh Abrar Hashishi Department of Family and Community Medicine College of Medicine, Dammam University, Saudi Arabia Correspondence: Manal Riad Koura Zamil compound, Unit B3-6 PO Box 899 Khobar 31952 Saudi Arabia Cell phone number: 00966-50 194 6517 Fax number: 00966-3- 864 5612 Email: mkoura@ud.edu.sa Abstract Background & objective: The aim of the present study was to identify the causes of stigma associated with psychiatric diseases and methods of its alleviation in Saudi Arabia. Methods: Sixteen focus groups were conducted in half of the Primary Health Care (PHC) centers of Khobar. The average number of adult female PHC attendees participating in each session was six. Each session lasted between 45-60 minutes. Each session was conducted by 3 female researchers. The moderator followed a semi-structured questionnaire for asking about reasons of stigma associated with psychiatric diseases and how to overcome such a stigma. Ten sessions could be audio-recorded after taking the consent of participants. The rest were transcribed by the assistant moderator. Collected data was analyzed for repeated themes and some quotations were selected. Results: Useful opinions were given, which might help in alleviation of stigma, like: Providing mental health services by PHC centers or general hospitals to avoid the embarrassment associated with visiting psychiatric hospitals. Since many people seek “Sheikhs” for mental problems, Muslim clergymen may participate in health education campaigns for alleviation of stigma. Providing mental health consultation by a psychologist at school and involving the children and their families in solving the problem might help in increasing acceptability of psychiatric services early in childhood. Providing a hot line for psychiatric consultation might reduce embarrassment. Conclusion: Reducing the stigmatization of mental illness continues to be an important goal for mental health professionals in our community. Key words: stigmatization, psychiatry Introduction Erving Goffman defined stigma as the process by which normal identity is spoiled by the reactions of others [1]. Stigmatization of individuals with mental illnesses is widespread and serves as a major barrier to treatment [2]. The public generally holds negative stereotypes toward individuals with psychological problems, leading to potential discrimination toward these individuals. The internalization of these negative beliefs results in self-stigma, leading to reduced selfesteem and motivation to seek help [3]. Research on psychological correlates of stigmatization of mental illness has shown that an important and surprising predictor of stigma is the greater belief in biological or genetic bases of mental illness [4]. Phelan theorized that genetic causes of mental illness are perceived as permanent, which raises discomfort because of the implication that complete recovery is impossible. Conversely then, optimism about the effectiveness of treatment might be expected to reduce stigma [5]. Stigma may be obvious and direct, such as someone making a negative remark about your mental health condition or your treatment. Or it can be subtle, such as someone assuming you could be violent or dangerous because you have a mental health condition. These and other forms of stigma can lead to feelings of anger, frustration, shame and low self-esteem, as well as discrimination at work, school and in other areas of life. For someone with a mental illness, the consequences of stigma can be devastating. Some of the harmful effects of stigma include: trying to pretend nothing is wrong, refusal to seek treatment, rejection by family and friends, work or school problems or discrimination, difficulty finding housing, being 44 MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 6 MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10
CLINICAL RESEARCH AND METHODS subjected to physical violence or harassment or inadequate health insurance coverage of mental illnesses [6]. The focus group method is a technique of group interview that generates data through the opinions expressed by participants. Focus groups have become an increasingly popular method of data collection in health care research. Since stigma associated with psychiatric diseases is a social related problem, focus group technique is thought to be the best methodology to understand the attitudes of the Saudi community. Our aim was to identify the causes of stigma associated with psychiatric diseases and methods of its alleviation in Khobar, Saudi Arabia. Methodology A qualitative research was conducted in four out of eight PHC centers in Khobar. Health centers with the largest population were selected. Sixteen focus groups were conducted during November 2010. Adult female consumers, attending the health centers for any reason were invited to participate in the study. The average number participating in each session was six. Each session lasted between 45-60 minutes. Each session was conducted by three female researchers. The moderator ran the session following a semi-structured questionnaire. She asked about the participant’s opinion about the magnitude of mental health problems in Saudi society, type of care the community seeks in case of mental health problems, the attitude towards seeking a psychiatric consultation, reasons of stigma associated with psychiatric diseases and how to overcome such stigma. She ensured that everyone had a chance to say what they wished to and that the group was not dominated by one individual. She also kept neutral during the whole session. One assistant moderator audiorecorded or transcribed the session. The other assistant moderator was responsible for observing and reporting the non-verbal responses. Ten sessions could be audiorecorded after taking the consent of participants and assuring them about the confidentiality of the gathered information, while transcripts were made for the rest. At the end of each session summary comments were verified with the participants to check if they really represented their opinions. Sessions were conducted until no new data emerged. Collected data was analyzed for repeated themes and some quotations were selected. Results and Discussion It should be noted that this research is qualitative in nature. Its purpose is not to find how many people are engaged in a certain behavior or hold a certain opinion, but to identify the kinds of behavior and opinion that exist, and the possible reasons for this behavior. Type of care the community seeks in case of mental health problems: - It was frequently mentioned that some patients seek help of their family or friends first and then may consult the psychiatrist, as many girls would turn to their mothers in solving their problems. - On the other hand, it was also reported that many patients go to “sheikhs” (religious people) for treatment by Qur’an. However, others think that most patients even refuse to go to the sheikh. o It was stated that: “People who have severe psychiatric problems may even attempt suicide to be relieved before seeking psychiatric care”. - A minority of people seek medical advice from a psychiatrist when they have mental health problems. However, they prefer to keep it secret or consult psychiatrists away from their community. - Some participants stated that acceptance of psychiatric counseling differs by age (young generations would accept it more than the older generations) and gender (females would accept it more than males). The study conducted by Mann and Himelein about factors associated with stigmatization of persons with mental illness, reported similar findings as stigmatization among females was significantly less than among males [2]. Although the word “stigma” indicates something negative or shameful, stigma may also be useful. As David Shaffer has pointed out, “we need to destigmatize mental illness and its treatment … but we do not want to destigmatize suicide and suicide attempts.” The harmful effects resulting from destigmatization of suicidal behavior is that it may normalize it and make it appear more reasonable [7,8]. The only study conducted in Saudi Arabia for investigating the parasuicide phenomena reported a parasuicide rate of 20.7 per 100,000 in an Arab industrial community in the Eastern Province [9]. It is substantially lower than the reported rates in the West, which range between 3-5% [10]. The results of the study confirm that the act is predominantly the activity of young females, and disordered interpersonal relationships with spouses and parents stand out as precipitating factors. Acute reaction to stress was the commonest diagnosis followed by depression [9]. Accordingly, we believe that Islamic rules prohibiting suicidal behavior play an important positive role in stigmatization of suicidal attempts. The systematic review conducted by Gulliver et al. in 2010 for perceived barriers and facilitators to mental health help-seeking revealed that only 35% of those surveyed with a common mental disorder sought help during the previous year. Analysis of qualitative studies revealed that the most frequently mentioned barrier was stigma, which was reported in over three-quarters of the studies. In addition, almost half of the studies cited issues related to confidentiality and trust. Over one-third of studies referred to concern about the characteristics of the provider and reliance on self as perceived barriers to help-seeking. Friends and family were often the preferred sources of help over health professionals. MIDDLE EAST MIDDLE JOURNAL EAST OF JOURNAL FAMILY MEDICINE OF FAMILY VOLUME MEDICINE 10 ISSUE • VOLUME 6 7, ISSUE 10 45
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